The National Institute of Health and Clinical Evidence (NICE) describes a 4-step approach to the management of Common Mental Health Disorders 23
- Step 1: Recognition, assessment, and initial management (including non-specific support and review)
- Step 2: Persistent sub-threshold depressive symptoms or mild to moderate depression or anxiety disorder
- Step 3: Persistent sub-threshold depressive symptoms or mild to moderate depression or anxiety disorder with inadequate response to initial interventions, and moderate and severe depression
- Step 4: Complex and severe depression or anxiety disorder, risk to life or severe self-neglect
Key clinical issues in providing an effective service offering NICE-approved therapies for the management of common mental health problems are:
- Recognising and accurately diagnosing common mental health problems
- Providing comprehensive assessment and accurately
- Differentiating between people with either mild/moderate depression or severe depression, identifying PTSD despite the presence of comorbidities and assessing the degree of functional impairment of people with OCD
- Ensuring that:
- a range of low-intensity services are provided
- high-intensity interventions by competent therapists 24
- IAPT services are integrated with other services for people with depression, OCD, PTSD or anxiety to ensure continuity of care providing a quality assured service.
NICE recommends Cognitive Behavioural Therapy (CBT), couples therapy, counselling for depression and brief dynamic therapy:
- Roughly half of all mental illness consists of anxiety conditions (like social phobia, health anxiety, PTSD, OCD, panic disorder or generalised anxiety). If untreated, these conditions are frequently lifelong.
- After an average of 10 sessions of CBT costing £750, around half of patients with anxiety and depression will recover within 4 months: for depression, likelihood of relapse is significantly reduced (but not eliminated). The short-run success rate with CBT is similar to that of drugs but the effects are more long-lasting.
- 50% recovery rates are those expected from a mature service and are now being approached in the Improving Access to Psychological Therapies (IAPT) services, where recovery rates have reached 43%, despite much of the work still being done by trainees or newly-trained staff. 2
- Reliable rates (meaningful clinical improvement) are higher – 65%; No change – 28%; Deterioration rates – 7%.
Effectiveness of IAPT: demographic, therapeutic and outcome data on depression and anxiety collected from 7859 consecutive patients for 24 months: 25
- Following up these patients for a further one year 4183 patients (53%) received two or more treatment sessions.
- Uncontrolled effect size for depression was 1.07 (95% CI: 0.88 to 1.29) and for anxiety was 1.04 (0.88 to 1.23).
- 55.4% of treated patients met reliable improvement or reliable and clinically significant change criteria for depression: 54.7% for anxiety.
- Patients received a mean of 5.5 sessions over 3.5 h, mainly low-intensity CBT and phone based case management.
- Attrition was high with 47% of referrals either not attending for an assessment or receiving an assessment only.
- Recovery rates for patients receiving stepped care empirically supported treatments for anxiety and depression in routine practice are 40 to 46%.
Only half of all patients referred to IAPT go on to receive treatment. Further work is needed to improve routine engagement of patients with anxiety and depression.
Key findings from first year of IAPT were: 26
- IAPT services appear to be beneficial to patients with clinical presentations that range from mild to severe. Patients with higher initial depression (assessed by the PHQ-9) and anxiety (assessed by the GAD-7) scores were less likely to meet criteria for recovery at the end of treatment. However, the overall amount of symptomatic improvement observed in severe cases was larger than that observed in mild cases.
- Self-referred patients were as severe as GP referred patients but recovered with fewer sessions of treatment.
- Services that make good use of stepped care have higher overall recovery rates. It was estimated that the average recovery rate for year one services could have risen from 42% to between 48% and 54% if step up from low to high intensity had been more consistently offered.
- Compliance with NICE treatment recommendations is associated with better clinical outcomes. When considering high intensity treatments, NICE recommends both CBT and counselling for mild to moderate depression but only recommends CBT for any of the anxiety disorders. An analysis of the recovery rates amongst patients who had both pre and post treatment scores on the PHQ-9 and GAD-7 was broadly in line with NICE recommendations.
- Services that provided a larger average number of treatment sessions had higher overall recovery rates. However the average number of sessions in the services with the best recovery rates was still fairly modest, estimated at between 8 and 10.
- A substantial number of people who do not meet recovery criteria in IAPT services still showed some benefit. Overall, 64% of patients in the year one IAPT services showed reliable improvement. Most of the remainder (29%) showed no reliable change and a small proportion (7%) showed reliable deterioration.
- Services that had a higher proportion of experienced therapists had higher overall recovery rates. There was a significant correlation between the proportion of therapists at a site that were employed at Agenda-for-Change band 7 or above and the recovery rate of the site. IAPT services should therefore have a core of fully trained, experienced therapists to supervise, to model therapy, and to treat more complex cases.
- Provisional diagnoses are important to ensure that patients receive NICE recommended treatments and have their outcomes appropriately monitored. NICE guidance is based on ICD-10 codes.
There are a substantial number of people with:
- Inadequate response to initial interventions,
- Persistent moderate depression
- Complex and severe depression
Response may occur to change in treatment, e.g. antidepressants or alternative high intensity NICE-approved therapy.
The majority of this group will either be supported in primary care, psychiatric outpatients or by mental health teams. Research into effectiveness of these interventions is limited:
- Collaborative care in the US involves ‘a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient’s primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care‘(the target group included patients who would have been eligible for IAPT in the UK).
- It has been found to be highly successful at improving depression symptoms (effect size=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (effect size=0.12); and care satisfaction with care (effect size=0.39)27.
- Service users and carer expect choice of care from CMHT, outpatients, primary care team or general practitioner (collaborative with mental health services or alone).
Mild to moderate problems (other conditions):
- Bipolar disorder, psychosis and emotional difficulties (‘borderline personality disorder’) can present as mild to moderate conditions or be in remission.
- Evidence for the differential effectiveness of management of these conditions in primary or secondary care is limited to expert opinion and service user and carer preferences.
- Evidence-based services that need to be available in either setting (NICE specified) include:
- support for adherence to medication and other interventions.
- provision of social support to minimise isolation and self-neglect.
- physical health monitoring.
- cognitive behaviour therapy for common mental disorders, psychosis or bipolar disorder.
- psychological interventions for ‘borderline personality disorder’.
- couple support and therapy.
- family support, education and work.
- early intervention to prevent relapse.
- rapid access to 24 hour services.